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Jul 16, 2023

What is a salpingectomy? The cancer

I started talking to my doctor about sterilization in the second trimester of my second pregnancy. I’d recently found out I’d need a C-section, thanks to a placental abnormality that made it unsafe

I started talking to my doctor about sterilization in the second trimester of my second pregnancy. I’d recently found out I’d need a C-section, thanks to a placental abnormality that made it unsafe for me to go into labor. I was mourning the birth experience I thought I’d get to have, and I felt, on some level, like a failure. Not having to worry about birth control anymore felt like a way to get something positive out of a situation I hadn’t chosen.

My husband and I also knew that, after our second son was born, we didn’t want more children. We only had the space — in our apartment, and also in our minds and lives — for two. I vaguely remembered that older relatives had gotten their “tubes tied” after a C-section, so I asked my obstetrician if that was still an option. She told me the preferred procedure these days is to remove the tubes entirely, an operation called a salpingectomy.

I didn’t know it then, but this brief surgery — it adds about five minutes to a cesarean delivery — was about to have a big moment. In January, the Ovarian Cancer Research Alliance (OCRA) issued a statement recommending that all women consider salpingectomy if they’re having another abdominal surgery and don’t want to have future children. That’s because, in addition to providing permanent birth control, a salpingectomy also reduces the risk of ovarian cancer by up to 50 percent. “This is a very powerful opportunity for cancer prevention,” said Sarah DeFeo, the research alliance’s chief program officer.

Permanent, non-reversible contraception definitely isn’t for everyone. Sterilization in America retains a certain stigma, and doctors are sometimes unwilling to perform it, especially if a patient is young or doesn’t already have kids. The procedure also brings up equity issues, from the long history of American doctors forcibly sterilizing Black women and women with disabilities to the tendency to place the responsibility for birth control solely on women and their bodies.

In the wake of the Dobbs decision, however, interest in all forms of birth control is on the rise. And experts say everyone with fallopian tubes should have the opportunity to consider a salpingectomy, even if they never take it.

Tubal ligation as a method of permanent birth control has been around since the 1880s. The expression “getting your tubes tied” is a misnomer; doctors don’t “tie” patients’ fallopian tubes, says Kavita Arora, a professor of obstetrics and gynecology at the University of North Carolina at Chapel Hill and chair of the ethics committee of the American College of Obstetricians and Gynecologists. Instead, each tube can be closed off with a clip, band, or ring; it can be cauterized; or it can be cut. The goal is to interrupt the egg’s progress down a fallopian tube so that it can’t encounter sperm and be fertilized.

In a salpingectomy, rather than cutting or obstructing the tubes, doctors simply remove them. The procedure is about as old as tubal ligation, and has long been used as a treatment when a fallopian tube ruptures as a result of an ectopic pregnancy. Over the last decade, however, researchers have come to believe that many ovarian cancers start out in the fallopian tubes. Ovarian cancer is relatively uncommon, with 19,710 women diagnosed in the US every year — for comparison, 264,000 women are diagnosed with breast cancer annually — but it is very deadly, accounting for more deaths than any other cancer of the female reproductive organs. Screening and early detection, unfortunately, do not appear to help patients live longer. That fact has led researchers to look for ways of stopping the disease before it starts.

Salpingectomy looks promising. One 2022 study found that removing the fallopian tubes was associated with significantly lower risk of ovarian cancer: Among 25,889 people who underwent a salpingectomy, none developed the disease during the nine-year study period. Since the procedure leaves the ovaries intact, it doesn’t cause menopause or change a patient’s menstrual cycle. Though the long-term effects are still being studied, “it’s generally considered to have very little impact on quality of life,” DeFeo said. While tubal ligations can sometimes be reversed, removal of the tubes is not reversible. Patients can still become parents, however, by IVF, surrogacy, or adoption.

If it’s done on its own, salpingectomy can have a recovery period of about two weeks. When done as part of another abdominal surgery, like a C-section, hysterectomy, or fibroid removal, the procedure adds very little, if any, to the recovery time. That’s one reason the Ovarian Cancer Research Alliance recommended that patients consider an “opportunistic salpingectomy,” or getting the procedure done when they’re already on the operating table for something else.

I had never heard of a salpingectomy until my doctor mentioned it to me, even though I’ve been reporting on reproductive health for nearly 15 years. At first I was nervous: The idea of permanent birth control appealed to me, but I wasn’t sure if I wanted to lose parts of my body. I was worried that, on some level, I’d miss them, or that I would come out of the procedure feeling somehow different or lesser. I tried to find personal stories of people who’d already been through the procedure, but because salpingectomies for birth control are relatively new, I didn’t find much.

For years, “women were really relying on their clinicians to recommend this, but didn’t have knowledge of it on their own,” DeFeo said. While doctors in major urban centers were often aware of the potential benefits of the procedure, that awareness didn’t always extend across the country, said OCRA CEO Audra Moran, or to other specialties outside of gynecology.

It wasn’t until 2013 that the Society of Gynecologic Oncology recommended that doctors discuss the procedure with patients, and the American College of Obstetricians and Gynecologists did the same in 2019. Today, most people who request a tubal ligation will probably be offered a salpingectomy, said Erin Medlin, a gynecologic oncologist at Colorado Permanente Medical Group. The health benefits are thought to be greater, though more conventional tubal ligation may also reduce ovarian cancer risk. In cases where scar tissue or another problem makes the procedure difficult, a more conventional ligation can still be done instead, Medlin said, but generally, doctors today are more likely to perform salpingectomies.

But most people still don’t know the procedure exists. In many ways, my generation of birthing people is the first to be offered opportunistic salpingectomy as an option. “Most women going into this surgery know what their mother had, which was some type of clip placed on their tube, or something of the like,” Medlin said. For people considering the surgery, there simply isn’t a wealth of generational experience to fall back on.

In addition to a lack of knowledge, patients can face another obstacle: doctors’ preconceptions around permanent methods of birth control. Patients have reported being denied sterilization procedures if a doctor perceives them as too young, or if they have not yet had children. “Some of it is very paternalistic,” Arora said.

On the other hand, some patients have historically been pressured or forced into sterilization. Between 1929 and 1974, for example, the state of North Carolina forcibly sterilized more than 7,600 people deemed to be “mentally defective;” the program specifically targeted Black residents. More than 30 states had compulsory sterilization laws on the books in the 20th century, and while many have been repealed, the practice isn’t necessarily a thing of the past. A 2013 investigation found that more than 100 incarcerated women in California had been sterilized without proper approval, and some reported being coerced.

“The history of sterilization is intertwined with the history of eugenics,” said Krystale Littlejohn, a sociology professor at the University of Oregon who studies race, gender, and reproduction. Doctors shouldn’t talk to patients about salpingectomies or any sterilization procedure without being mindful of that history and the danger of repeating that coercion, even unintentionally, experts say. “It’s really important to think about the context in which people are encouraged to use particular methods or to pursue particular surgical options and to think about the deeper meanings that those options have for them,” Littlejohn said.

Getting a salpingectomy or any form of permanent birth control can also be difficult because a certain aura of shame still surrounds the idea. “There are so many parts of women’s health care that are stigmatized, that we don’t talk enough about, whether that’s cesarean deliveries or miscarriages or sterilization or Pap smears,” Medlin said. Even within the realm of reproductive health, sterilization can be tricky to bring up because it’s associated with not wanting children, an attitude that’s still viewed as suspect by many Americans, even as more and more people are choosing to remain child-free. In my own life, I had a much easier time finding information and perspectives about reversible forms of contraception, like the pill or ring, than about a procedure that would be permanent. Even talking about the possibility felt a little taboo; I wondered if I should be embarrassed.

Insurance can also be a hurdle. As a form of birth control, salpingectomy is covered by the contraceptive mandate in the Affordable Care Act, which requires employer-provided health plans to cover birth control without a copay. However, that mandate was significantly weakened by the Trump administration and has never covered people without employer-provided insurance. As of 2021, 10.2 percent of Americans had no health insurance at all; without insurance, a salpingectomy can cost thousands of dollars.

Moreover, conversations around birth control in America, including sterilization, have typically placed the onus on women and people who can become pregnant. “There’s just this expectation that women should be responsible for preventing pregnancy,” Littlejohn said. That inequity often extends to sterilization. By the time they consider such a procedure, many women have already been shouldering for decades the responsibility of birth control. So “it can seem like a natural step for some of them” to be the one to undergo sterilization. Tubal sterilization procedures are more common than vasectomies, even though the latter is often less invasive.

Sterilization in general has been getting more attention since the Dobbs decision last summer resulted in abortion bans in many states. Procedures such as salpingectomy, however, will never be a substitute for abortion rights, Littlejohn said.

“People need bodily autonomy,” she said. “Dobbs is an assault on their bodily and reproductive autonomy, and to suggest that they just get sterilized because they no longer have the option of getting an abortion is also encroaching on their reproductive autonomy.”

At the same time, “clinicians should not impose paternalistic thresholds on whom they will and will not perform permanent contraception on,” Arora said. “The patient is the expert in their own lives.”

When I started discussing sterilization with my doctor, I didn’t necessarily feel like an expert. What helped me decide and feel confident in my decision was talking to other people in my life. My husband and I talked about the pros and cons, but it was clear to both of us that the final vote should be mine; I had already been through a lot to build our family, and if I was going to undergo another medical procedure to finish building it, the decision would have to be mine alone. I also talked to my best friend, who helped me run through a list of all possible scenarios in which I might regret the decision. As we spoke, I began to lose my anxiety and feel, instead, a sense of self-determination.

Ultimately, I decided to get the surgery mostly because of its potential to reduce my cancer risk. There are other methods of birth control, but the idea of a surgery that could protect my future health, and that would be over in a few minutes with minimal side effects, was appealing to me. When the time came, I barely noticed the salpingectomy was happening — I was so focused on the baby who had just been lifted, wailing, from my body.

He’s about 8 months old now, and I’m glad I got the surgery when he was born. If it prevents me from getting ovarian cancer, I’ll never know it — that’s the nature of prevention. But it’s a choice the Ovarian Cancer Research Alliance wants more patients to have. “We’re not advocating for every single woman in America to have an opportunistic salpingectomy,” Moran said, “but just to talk about it and ask the questions.”

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